Case report
A new case of Job's syndrome at the clinic: A diagnostic challenge
Um novo caso de síndrome de Job na clínica: um desafio de diagnóstico
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Froes, A. Diniz, C. Robalo Cordeiro, M. Serrado, A. Ramalho de Almeida" "autores" => array:5 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Froes" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Diniz" ] 2 => array:2 [ "nombre" => "C. Robalo" "apellidos" => "Cordeiro" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Serrado" ] 4 => array:2 [ "nombre" => "A. Ramalho" "apellidos" => "de Almeida" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215914000099?idApp=UINPBA00004E" "url" => "/08732159/0000002000000002/v4_201509041359/S0873215914000099/v4_201509041359/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0873215913001049" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2013.06.007" "estado" => "S300" "fechaPublicacion" => "2014-03-01" "aid" => "174" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Pneumol. 2014;20:101-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 9561 "formatos" => array:3 [ "EPUB" => 264 "HTML" => 7584 "PDF" => 1713 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Linfangioleiomiomatose pulmonar inicial provável e linfangioleiomioma mediastínico" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "101" "paginaFinal" => "106" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Probable initial pulmonary lymphangioleiomyomatosis and mediastinal lymphangioleiomyoma" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 996 "Ancho" => 1348 "Tamanyo" => 463848 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A) Positividade citoplasmática para actina de músculo liso. B) Positividade multifocal para HMB-45. A positividade é mais evidente nos agregados epitelióides. C) Fendas com positividade no revestimento para CD34 – Espaços sinusoidais. D) Positividade nuclear para estrogénio.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Pontes, C. Barbosa, M.L. Coelho, L. Carvalho" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Pontes" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Barbosa" ] 2 => array:2 [ "nombre" => "M.L." "apellidos" => "Coelho" ] 3 => array:2 [ "nombre" => "L." 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Cruz‐Portelles, D. Estopiñan‐Zuñiga" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Cruz‐Portelles" "email" => array:1 [ 0 => "alain@hvil.hlg.sld.cu" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Estopiñan‐Zuñiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Critical Care Medicine Department, V. I. Lenin University General Hospital, Holguín, Cuba" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Internal Medicine Department, V. I. Lenin University General Hospital, Holguín, Cuba" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Um novo caso de síndrome de Job na clínica: um desafio de diagnóstico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 591 "Ancho" => 1300 "Tamanyo" => 86573 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph on admission (A: posteroanterior and B: lateral view) showing multiple thin‐walled cyst (pneumatoceles) with air‐fluid level (*).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of primary immunodeficiency (PI) is underestimated worldwide. In the United States, the calculated prevalence of diagnosed PI is 1 in 1200 people of all ages.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Hyperimmunoglobulin E syndrome (HIES) is among the earliest described syndromes of immunodeficiency characterized by recurrent and severe pneumonia, eczema, and markedly high levels of immunoglobulin E (IgE). Both male and female are affected and familial or sporadic cases have been reported worldwide. The authors present a new case of HIES, lately diagnosed, with severe pulmonary sequellae.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case history</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 25‐year‐old man came to the hospital complaining of mild shortness of breath, cough with a yellowish expectoration, weakness and profuse unexplained sweating without fever. The first symptoms had started three month before. He was a nonsmoker and had no history of environmental exposure to chemicals or dust. His medical history was positive for dermatitis since the first 24<span class="elsevierStyleHsp" style=""></span>h of his life, recurrent severe staphylococcal pneumonias with empyema, chronic external otitis, sinusitis and dermatitis. He also showed pathological fractures of the seventh left rib, intercostal herpes‐zoster at two years of age. Frequent episodes of severe infectious diarrhea were also reported. His family history was unremarkable.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination, the patient's body size was smaller than normal for his age and sex. His face was coarse, with prominent forehead, broad nasal bridge, and facial asymmetry. Marked joint hyperextensibility and scoliosis was found. Chest examination showed a respiratory rate of 24 breaths/min with crackles in the left base. His skin showed signs of pruritic chronic dermatitis spread all over, mainly at his legs, arms, and axillae. Onychomycosis was present at his fingernails with clubbed fingers. The rest of the vital signs and physical examination were unremarkable.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory findings included: Hb: 11.0<span class="elsevierStyleHsp" style=""></span>g/dL, WBC count: 15.0<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L with 10% eosinophils and 52% neutrophils, erythrocyte sedimentation rate: 80<span class="elsevierStyleHsp" style=""></span>mm/h, alkaline phosphatase: 211<span class="elsevierStyleHsp" style=""></span>U/L [reference range (RR): 35–150<span class="elsevierStyleHsp" style=""></span>U/L]. No other metabolic abnormalities were observed. Alfa‐1 antitrypsin, serum IgA and IgM levels were within normal limits. IgG: 17.0<span class="elsevierStyleHsp" style=""></span>g/L (RR: 6.4–13.5<span class="elsevierStyleHsp" style=""></span>g/L) and IgE: 21,300<span class="elsevierStyleHsp" style=""></span>U/mL (RR: 10–179<span class="elsevierStyleHsp" style=""></span>U/ml) were high. A chest radiograph performed on admission showed multiple thin‐walled cysts with air‐fluid level consistent with superinfection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The thorax CT scan alterations are showed in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Topical antibiotic and steroids creams, oral ketoconazole, and ceftriaxone and azithromycin were initially used without a significant improvement. On the fifth day of treatment a sputum culture with meticillin resistant <span class="elsevierStyleItalic">S. aureus</span> was received and vancomicin was initiated with excellent results. No other germs were isolated on blood or sputum cultures. The diagnosis of sporadic form of HIES (Job's syndrome) was made based on clinical and laboratory findings. Skin lesions improved and prophylactic treatment with trimethoprim‐sulfamethoxazole was recommended.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">There are two forms of HIES: an autosomal‐dominant form caused by mutations in signal transducer and activator of transcription (<span class="elsevierStyleItalic">STAT)3</span> (gene location 17q21),<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and a recessive form frequently associated with dedicator of cytokinesis (<span class="elsevierStyleItalic">DOCK)8</span> mutations (9p24) or tyrosine kinase (<span class="elsevierStyleItalic">TYK)2</span> (19p13.2) mutations. The dominant form (familial or sporadic) is characterized by skeletal, connective tissue, recurrent pulmonary infections and eczema. Autosomal‐recessive HIES is present with recurrent viral and staphylococcal skin infections, frequent central nervous system abnormalities and vasculitis. This form exhibits a higher mortality and a lack of tendency to pneumatoceles formation.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Inheritance usually follows an autosomal dominant pattern with variable penetrance being the autosomal recessive pattern infrequent.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Pathogenesis is complex and not very well understood. Originally, HIES was consider to be due to a defect in neutrophil chemotaxis but this is not a constant feature. Leucocytes of HIES patients have defective cytokine‐mediated signal transduction through the Janus Kinase (<span class="elsevierStyleItalic">JAK</span>)‐<span class="elsevierStyleItalic">STAT</span> pathways. <span class="elsevierStyleItalic">STAT3</span> is a major signal transduction protein involved in diverse pathways including wound healing, angiogenesis, immune pathways, and cancer. HIES patients have impaired differentiation of Th17 T cells from mutations in <span class="elsevierStyleItalic">STAT3</span>.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Experimental models in which Th17 cells or Th17 cell‐dependent cytokines are defective have shown that immunity to several extracellular bacteria, including <span class="elsevierStyleItalic">Staphylococcus aureus</span>, <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> and <span class="elsevierStyleItalic">Candida albicans</span>, is impaired.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">IgE synthesis is normally enhanced by the Th2 cytokines IL‐4 and IL‐13, and repressed by Th1 IFN‐γ and IL‐12. The two responses act in opposition to each other. Decreased production of IFN‐γ by T cells has been demonstrated in HIES patients and is probably related with hyper‐IgE.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Eosinophilia almost always is present in these patients, at least at some point, but is not correlated with the serum IgE level or with the susceptibility to severe infections; some older patients whose IgE levels were consistently low still suffered recurrent infections.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A newborn rash is usually the first manifestation of <span class="elsevierStyleItalic">STAT3</span> deficiency characterized by a fine papular erythematous eruption with superficial vesicles and pustules. This rash which may be located to the face, scalp, or body folds and is refractory to traditional topical treatment. These areas are typically spared in atopic dermatitis. Boils, cold abscesses, and chronic onychomycosis can be found.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Severe and recurrent bacterial pneumonias are often recognized during childhood. The diagnosis is frequently delay due to the lack of evident inflammatory signs contributing to the advance of the infection and pneumatoceles and bronchiectasis formation that predispose to secondary infections. Frequent pathogens isolated in HIES are <span class="elsevierStyleItalic">S. aureus</span>, <span class="elsevierStyleItalic">Streptococcus pneumoniae, H. influenzae</span>, and <span class="elsevierStyleItalic">Candida</span> that typically respond promptly to appropriate antimicrobial therapy. Secondary infections are often caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, <span class="elsevierStyleItalic">Aspergillus</span>, and nontuberculous mycobacterias and have been more frequently associated with complications and mortality than primary infections.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Characteristic craniofacial features resemble one another HIES patients more than their own family members. Facial characteristics include coarse face, prominent forehead, a broad nasal bridge, prognathism, facial asymmetry, and retained primary teeth. Skeletal manifestations such as joint hyperextensibility, scoliosis, osteopenia, pathologic fractures, and Chiari 1 malformation have been reported.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Vascular alterations such as dilation, tortuosity and aneurysms of middle‐sized arteries producing myocardial and brain lacunar infarction, as well as arterial hypertension have been observed.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The incidence of malignant disease in HIES is higher, particularly non‐Hodgkin's and Hodgkin's lymphoma.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis is made based on: (1) clinical findings ‐mentioned above‐ guided by a scoring system originally developed with genetic linkage studies<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>: a patient with a punctuation higher than 14 is considered affected, (2) lab findings that include mild to moderate eosinophilia in over 90% of patients and markedly high IgE (>10 times normal) levels, and (3) genetic tests. The latest should be performed for confirmation but mutations are not always found and genetic analyses are not available in all medical centers. The most important differential diagnosis for HIES eczema is atopic dermatitis. Other PI disorders like Omenn syndrome, Wiskott–Aldrich syndrome, and Netherton syndrome have to be ruled out.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Treatment of patient with HIES focuses on the following:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Skin care. Effective skin care often depends on control of skin infections. Bleach baths and swimming in chlorinated pools are highly effective in patients with severe dermatitis. Topical corticosteroids and antibiotics, and hydrating measures for eczema, is essential.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Antimicrobial prophylaxis. <span class="elsevierStyleItalic">S. aureus</span> infection prophylaxis is often given. Cotrimoxazole (2.5<span class="elsevierStyleHsp" style=""></span>mg/kg of the trimethoprim component twice daily), a semisynthetic penicillin, or an oral cephalosporin which targets <span class="elsevierStyleItalic">S. aureus</span> can be used. Frequency and length of antibiotic prophylaxis depends on medical decision because no controlled trials have been performed. The role of antifungal prophylaxis is unknown.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment of infections. Systemic bacterial or fungal infections are often severe and a selection of the correct antibiotic drug is crucial. Intensive treatment, focusing on the most probable pathogen trying to obtain its susceptibility, could be lifesaving. Although <span class="elsevierStyleItalic">S. aureus</span> is the most frequent germ reported as a cause of pneumonias, gram‐negative bacteria (including <span class="elsevierStyleItalic">Pseudomonas</span>) and fungus has been often recognized as a cause of complications and death.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Management of pulmonary complications. Empyema is relatively common and requires drainage. Pulmonary large cysts may become secondarily infected and be a source of infection, bleeding, and possibly death. On the other hand, thoracic surgery can be complicated by poor expansion of the remaining lung after surgery.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Immunomodulating agents. Intravenous immunoglobulin has been anecdotally used in HIES patients with low levels of antibodies after vaccination with inconsistent results.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Recombinant interferon‐γ improved neutrophil chemotaxis in few patients, and vaccination for preventing infections could help HIES. However, none of these treatments are actually recommended in the daily practice because no clinical trials have been performed at the present time.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Hematopoietic stem cell transplantation has been used in patients with HIES and B‐cell lymphoma with negative results and is not actually indicated.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0095" class="elsevierStylePara elsevierViewall">Other therapies. Isotretinoin, cyclosporin A, and plasmapheresis have been tested on a few patients but are not generally indicated.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,11</span></a> H<span class="elsevierStyleInf">2</span> antagonists like cimetidine seem to improve symptoms.</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">Prognosis of HIES patients depends on early diagnosis and prompt treatment of complications. Pulmonary infections, bleeding and lymphoma are among the leading causes of death. Several studies have shown that many cases of PI are diagnosed late or are never diagnosed. Some cases may be missed because the patient dies before life‐threatening complications from HIES are diagnosed.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Identification of most children/adults with PI relies on the awareness of their physicians and a high index of suspicion leading to prompt referral to specialists trained in the management of these complex diseases.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres547647" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec565526" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres547646" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec565527" "titulo" => "Palavras‐chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case history" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-04-05" "fechaAceptado" => "2013-07-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565526" "palabras" => array:6 [ 0 => "Job's syndrome" 1 => "Hyperimmunoglobulin E syndrome" 2 => "Bronchiectasis" 3 => "Case report" 4 => "Eosinophilia" 5 => "Primary immunodeficiency" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras‐chave" "identificador" => "xpalclavsec565527" "palabras" => array:6 [ 0 => "Síndrome de Job" 1 => "Síndrome de hiperimunoglobulina E" 2 => "Bronquiectasia" 3 => "Relatório de caso" 4 => "Eosinofilia" 5 => "Imunodeficiência primária" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Job's syndrome or Hyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency characterized by recurrent soft tissue infections, coarse face, skeletal and vascular abnormalities, and markedly high levels of Immunoglobulin E. Eczema that resembles atopic dermatitis but is refractory to traditional treatment and severe and recurrent bacterial pneumonias often recognized during childhood. Early diagnosis and treatment prevent progressive pulmonary sequellae and increase survival. About 200 cases of HIES has been reported worldwide. The authors report a new case of HIES with one of the worst pulmonary sequellae found in the literature on this subject and review this infrequent topic.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A síndrome de Job, ou síndrome de Hiperimunoglobulina E (HIES), é uma rara imunodeficiência primária caracterizada por infecções recorrentes de tecidos moles, anomalias grosseiras faciais, esqueléticas e vasculares, e níveis visivelmente elevados de Imunoglobulina E. O eczema semelhante à dermatite atópica, mas refractário ao tratamento tradicional e pneumonias graves e recorrentes são frequentemente reconhecidas durante a infância. Um diagnóstico e tratamento precoces impedem sequelas pulmonares progressivas e aumentam a sobrevivência. Foram relatados cerca de 200 casos de HIES em todo o mundo. Relatamos um novo caso de HIES com uma das sequelas pulmonares mais extensas encontradas na análise bibliográfica sobre este assunto, conjuntamente com uma revisão sobre esta patologia pouco frequente.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 591 "Ancho" => 1300 "Tamanyo" => 86573 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph on admission (A: posteroanterior and B: lateral view) showing multiple thin‐walled cyst (pneumatoceles) with air‐fluid level (*).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1049 "Ancho" => 2400 "Tamanyo" => 391101 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest CT scan on admission showed multiple and large pneumatoceles, some with air‐fluid level consistent with superinfection mainly at middle and lower lung fields, mild consolidation, bronchiectasis, and left pleural thickening.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Population prevalence of diagnosed primary immunodeficiency diseases in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.M. 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| 2015 February | 69 | 38 | 107 |
| 2015 January | 56 | 30 | 86 |
| 2014 December | 74 | 37 | 111 |
| 2014 November | 109 | 36 | 145 |
| 2014 October | 106 | 64 | 170 |
| 2014 September | 88 | 66 | 154 |
| 2014 August | 62 | 30 | 92 |
| 2014 July | 73 | 37 | 110 |
| 2014 June | 74 | 36 | 110 |
| 2014 May | 77 | 48 | 125 |
| 2014 April | 104 | 78 | 182 |
| 2014 March | 22 | 13 | 35 |
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